Shoulder 3 Flashcards
Remind yourself of the anatomy of the clavicle
What age groups are clavicular fractures common in?
HINT: bimodal
- Adolescents & young adults
- 60yrs (onset of osteoporosis)
What classification system is used to classify clavicular fractures?
Allman classification
Describe the Allman Classification
Type 1
- # middle third
- 75% (as middle third is weakest)
- Generally stable
- But significant deformity present
Type 2
- # lateral third
- 20%
- When displaced, they are unstable
Type 3
- # medial third
- 5%
- Associated multi-system polytrauma
- May be associated with neurovascular compromise, pneumothorax or haemothorax
Describe how the medial and lateral segment of clavicle will displace in a #clavicle
- Medial: elevate due to SCM
- Lateral: depressed due to weight of arm > strength/support from trapezius
Describe some common mechanisms of injury for #clavicle
- Direct trauma
- Indirect trauma e.g. fall onto shoulder
State symptoms of a #clavicle
- Pain
- Sudden onset
- Localised
- Severe
- Worsened by active movement of arm
What might you find on examination of someone with #clavicle
- Tenderness over clavicular region
- Deformity (medial elevation, lateral depression)
- Open injuries
- Threatend skin (tented, tethered, white & non-blanching skin. May convert to open injury)
What must you assess for if someone presents with #clavicle?
Neurovascular compromise
What investigations would you do if you suspect #clavicle?
- X-ray of clavicle (AP and modified axial)
- ?CT: might be needed to asses medial clavicle injuires as these can be hard to assess on x-rays
Discuss the management of #clavicle
Most managed conservatively even if there is significant deformity.
- Sling (to support elbow& improve deformity. Kept on until regain pain-free movement)
- Encourage early movement of shoulder
Surgery is required for open fractures. Surgery for other #clavicle is controversial. ORIF required if fracture failed to unite.
State some potential complications of #clavicle
- Non-union
- Neuorovascular injury
- Puncture injury to lung resulting in pneumothorax or haemothorax
What is the healing tiem for clavicular fractures?
4-6 weeks
Remind yourself of the anatomy of the humerus
Who are humeral shaft fractures common in?
HINT: bimodal
- Younger pts (high energy trauma)
- Older pts (low impact, osteopenia/osteoporosis)
State some risk factors for humeral shaft fractures
- Age
- Osteoporosis
- Previous fractures
State typical mechanism of injury in humeral shaft fracture
- Fall on outstretched limb
- Fall laterally onto adducted limb
What are symptoms of humeral shaft fracture?
- Pain
- Deformity
- If radial nerve involved:
- Reduced sensation dorsum 1st webspace
- Weakend wrist extension
What might you find on clinical examination of a pt with humeral shaft fracture?
- Deformity
- Weakness wrist extension
- Reduced sensation over dorsal 1st webspace
- Open wounds
What must you assess when examing a pt with #humeral shaft?
Neurovascular status
Where do majority of humeral shaft fractures occur?
Medial third
What nerve is at risk in #humeral shaft and why?
Radial nerve as it passes through radial groove then runs along lateral edge of humeral shaft
The radial nerve is most likely to be damaged in what type of humeral shaft fracture?
- Holstein-Lewis fracture
- Fracture to distal 1/3 of radius
- Results in entrapment of radial nerve
*Requires surgical management
What investigations are required for humeral shaft fractures?
X-ray: AP & lateral
Discuss the management of humeral shaft fractures
Mainstay of management= realignment of limb.
Conservative
- Humeral brace (used in most fractures of diaphysis)
- High elbow case (if very distal fracture of humerus)
- Regular follow up & repeated x-rays
Surgical
- Surgical fixation only needed in minority. Open reduction & internal fixation
How long does it typically take for the full union a humeral shaft fracture?
8-12 weeks
State some potential complications of humeral shaft fractures
- Non-union & mal-union (rare)
- Varus angulation (rarely causes functional limitation as shoulder can compensate)
- Radial nerve injury (90% improve in 3/12 without intervention)
Where is the most common site for a shoulder fracture?
Proximal humerus
Who do shoulder fractures commonly occur in?
Most commonly occur in elderly pts with osteoporosis who have fallen on outstretched hand
State some risk factors for a shoulder fracture
Risk factors are the risk factors for osteoporosis:
- Female
- Age
- Early menopause
- Prolonged steroid use
- Recurrent falls
- Frailty
State the symptoms of a shoulder fracture
- Pain aroudn upper arm & shoulder
- Restricted movement
- Inability to abduct arm
What might you find on clinical examination of someone with a shoulder fracture?
- Swelling
- Bruising
- Restricted movement
- Damage to axillary nerve:
- Loss of sensation in regimental badge area
- Loss of power of deltoid muscle
What should you always assess in a supsected shoulder fracture?
Neurovascular status
What investigations would you do in a suspected shoulder fracture?
- X-rays (AP, lateral scapular, axillary)
Others you may do:
- Trauma: urgent bloods- coagulation screen, group & save
- Pathological cause suspected e.g. cancer- serum calcium, myeloma screen
What classification system can be used to classify proximal humeral fractures?
*Don’t worry about details of it, just know neer classificaiton used to classify
Neer Classification: classifies fractures based on relationship between 4 main segments of proximal humerus. Classified as displaced if >1cm between segments or at least 45 degrees angulation. Classifies into minimal displacemtn or two to four part injuries.
- Greater tuberosity
- Lesser tuberosity
- Articular segment (anatomical neck)
- Humeral shaft (surgical neck)
Discuss the management of proximal humeral fractures
Majority managed conservatively:
- Immobilisation initially followed by early mobilisation at 2-4 weeks
- Polysling
- Physiotherapy
Srugery indicated if fracture is open, displaced or neurovascular compromise. Surgery may include ORIF, intermedullary nailing, hemiarthroplasty, reverse shoulder atrhoplasty.
State some potential complications of a proximal humerus fracture
- Reduced range of omotion
- Avascular necrosis of humeral head
Scapular fractures are very rare; true or false?
- True
- Scapula protected by surrounding muscles
- Associated almost exclusively with high impact trauma
- Majority treated non-operatively
- Good results & no functional deficits in most cases
